Dear Dr. Ermers,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This is a relevant and timely study. However, I have a few major concerns with the manuscript: 1) The applied Reflexive Thematic Analysis (of what consists this method) and the way the researchers proceeded with this method is not or poorly described; 2) Backgound of the researchers: "meaningful communication"? This is not a profession like the professions of the other researchers (palliative care, medical oncology, primary care), what is the professional background?; 3) Reading the discussion it clearly lacks expertise in and input from liaison psychiatry/psycho-oncology: why did the researcher not associate a professional with this background?; 4) Why do the authors describe the questionnaires? This is a qualitative study, and there is no articulation between the quantitative and qualitative data; 5) The discussion seems to me rather superficial and this is a shame, since the study is very interesting; to give a few examples: a) SDM is not the only objective of a consultation, crtitique towards the oncologists have therefore be attenuated, and SDM should be placed within the context of all other objectives (e.g., support); b) some phenomena such as the shared focus on anticancer treatment can be explained by collusion (see the recent reviews and studies by Stiefel et al.), and if collusion is at work, simply feedback the observation to oncologists will not do it (see the beforementioned (for approaches, see these papers); c) other reactions of oncologists such as presenting bad news positively or responding to patient's negative emotions positively is understandable when one turns to the psychology of the clinician (e.g., feelings of guilt to harm the patient psychologically, fear of the patient's emotions - see for example the recent ESMO Guidelines on communication in chronic cancer care, in which an important part is dedicated to the "psychology of the clinician"; d) the interconnection of the four findings should also be discussed in light of the psychology of the patient, of the clinician and their interactional dynamics. a) - d) is important to discuss, since the suggested ways to improve the situation will depend on. Again, just to restore these finding to oncologists will not modify their communication behaviour, since it's not about technique but psychology; psycho-oncology has means to modify these beahviours (communication training, indicidual and group supervision, etc.)

Reviewer #2: The article is well written overall and outlines important applied research in shared decision-making. In order to help make the writing, analysis and findings clearer there are parts of the manuscript that would benefit from improvement as follows:

1. Introduction: Well-written overall.

"Vicious" cycle: the how underlying this is unclear to me. Discussion of this and elaboration in the introduction would be useful. Some discussion of the mechanisms by which this might happen might also be helpful for next steps in intervention.

2. Results & Discussion: The authors make points, such as "no room for bad news". It would be helpful to comment on literature and/or theoretical frameworks that suggest why this might be the case? Is there a wider societal context at play here? Or is it medical oncologists' own values? How might these intersect? Thinking about what these codes and findings might mean in terms of how we deliver care might deepen the insights provided by the manuscript.

3. The paper itself might benefit from consideration of theory or theoretical frameworks that elaborate on decision-making. What sort of shared decision-making models have already been suggested? How do the findings compare? Do they map onto similar domains or do they deviate significantly?

4. I would have liked to also understand a little more about the reflexive approach applied by the authors - what were the positions they approached the analysis with? What were their biases, strengths and limitations?

5. Lastly quantitative measures have been included in the paper write up but I'm not sure how these compare to the qualitative data. Making this clearer and how both sources of data have been analysed would help clarify the findings presented in the research.

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Reviewer #1: No

Reviewer #2: No

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Communication Patterns in Decision-Making Consultations between Patients with Advanced Cancer and Medical Oncologists: A Qualitative Observational Study

PONE-D-25-13553R1

Dear Dr. Ermers,

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Kind regards,

Caroline Watts, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Apologies for the delay with this paper. Thank you for your patience and consideration of reviewers comments.

Reviewers' comments: